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Theses, Dissertations and Capstones

1-1-2009

The Effects of Anti-Depressant Advertising onPerception of Depression in College Students atMarshall UniversityDeirdre Robertsonderobertson@earthlink.net

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Recommended CitationRobertson, Deirdre, "The Effects of Anti-Depressant Advertising on Perception of Depression in College Students at MarshallUniversity" (2009). Theses, Dissertations and Capstones. Paper 158.

The Effects of Anti-Depressant Advertising on Perception of Depression in College Students at

Marshall University

Thesis submitted to the Graduate College of Marshall University

In partial fulfillment of the requirements for the degree of Master of Arts (Journalism and Mass Communications)

by

Deirdre Robertson

Dr. Chris Swindell Ph.D., Committee Chairperson

Professor Janet Dooley

Professor Dan Hollis

Marshall University

December 2009

ii

Table of Contents

Abstract……………………………………………………………………….iii

Chapter One: Introduction……………………………………………………1

Chapter Two: Review of Literature…………………………………………..5

Chapter Three: Methods………………………………………………………20

Chapter Four: Results…………………………………………………………26

Chapter Five: Discussion……………………………………………………...30

Chapter Six: Limitations and Recommendations……………………………..33

References………………………………………………………………...…..35

Figure 1.1: Anonymous Survey Consent Form...……………………………...41

Figure 1.2: Informed Consent Form.…………………………………………..42

Figure 1.3: Debriefing Form…………………………………………………...43

Figure 2.1: Results Chart………………………………………………………44

Figure 3.1: Questionnaire………………………………………………………45

Figure 4.1: Commercial Storyboard……………………………………….......47

iii

Abstract

The Effects of Anti-Depressant Advertising on Perception of Depression in College Students at

Marshall University

Deirdre Robertson

This exploratory study was designed to determine the effects, if any, of direct-to-

consumer advertising of anti-depressants on Marshall University students’ perceptions of

depression and anti-depressant medication. For the purposes of the study, two versions of an

advertisement were created: one including three false statements regarding depression and anti-

depressants, and one without false statements. A fifteen-question survey was also created as a

baseline to measure whether the advertisement condition had any direct effects on the

participants’ perceptions of depression and anti-depression and to provide comparison for the

participants’ reactions. All three groups took the survey. There were ninety participants in the

study, split into three groups of thirty, including a group that viewed the commercial with false

statements, a group that viewed the commercial without false statements, and a control group

that did not view any advertisement.

Analysis of the results revealed that there was not a significant link between the

information presented in the advertisement conditions and participants’ perceptions of depression

and anti-depressants. The participants’ responses on the survey did not appear to be influenced

by the false information in the advertisement. Results did not support the expectation that the

advertising condition would significantly alter the perceptions of college students regarding

depression and its treatment.

1

Chapter One: Introduction

More than 19 million American adults suffer from depressive disorders, according to the

American Psychological Association (APA) in 2007. At any given time, depression generally

affects 5% of the population (Goldney, Fisher, & Wilson, 2001). In fact, the disabilities

associated with Major Depressive Disorder (MDD) are surpassed only by those associated with

ischemic heart disease (Waraich, Goldner, Somers, & Hsu, 2004). When dealing with any such

prevalent disease, it is imperative to recognize symptoms, seek diagnosis, and receive

appropriate treatment. However, depression is not as easily recognizable as the flu or a cold, and

the general population is not well informed about its symptoms. Mental health literacy,

especially in terms of depression, is vital to controlling the prevalence of the disease (Waraich,

Goldner, Somers, & Hsu, 2004).

The increased prescription of anti-depressants has not necessarily been successful in

combating the elevating frequency of depression (de Jonghe, Hendriksen, van Aalst, Kool, Peen,

Van, van den Eijnden, & Dekker, 2004). There has been no success in finding biological

predictors in responses to anti-depressant treatment. What have been successful, however, are

investigations into psychological predictors for response; these findings have established that the

effectiveness of anti-depressant treatment can only be judged on a case-by-case basis and are

better determined by physicians with a psychiatric background (de Jonghe, et. al., 2004).

According to this study, the average physician is not qualified to create a psychiatric profile

detailed enough to determine whether or not anti-depressant treatment will be effective in most

patients; the increased prescription of anti-depressants based on direct-to-consumer advertising

supports this conclusion.

2

To understand the modern public conception of depression, one must look at modern

public information sources. Much of public knowledge comes from anti-depressant

commercials, magazine advertisements, and the Internet, not from accredited medical sources

(Goldney, Fisher, & Wilson, 2001). In 2000, the pharmaceutical industry spent 1.8 billion dollars

on direct-to-consumer-advertising (DTCA) of prescription drugs, most of which was spent on

television making it an important source of information for the general public (Polen, Khanfar, &

Clauson, 2009).

Advertising, and particularly television advertising, has long been recognized as a source

for individuals to learn and model behavior through social learning (Philips & Orton, 1983).

Albert Bandura‘s theory of Social Learning claims that individuals learn accepted social

behaviors and expectations through modeling or observing others and forming an idea of how

certain behaviors are performed; individuals then use this coded information to determine similar

actions in the future (Bandura, 1977). According to Bandura‘s theory, there are several levels of

observational learning, the first of which is achieved by first ―organizing and rehearsing the

modeled behavior symbolically and then enacting it overtly (Bandura, 1986).‖ The theory also

suggests that individuals are likely to adopt the modeled behavior if it demonstrates an outcome

valued or desired by the individual, particularly if the model is similar to the observer and has

admired status. For effective modeling, Bandura claims that the following conditions must be

met: first, attention must be paid; taking in considerations of factors which increase or decrease

attentions such as distinctiveness, affective valence, prevalence, complexity, and functional

value. Secondly, the observer must retain the information presented, typically using symbolic

coding, mental images, cognitive organization, symbolic rehearsal, and motor rehearsal. Thirdly,

for successful modeling, the modeled behavior must be reproduced, including the use of physical

3

capabilities and self-observation. Finally, the observer must be motivated or presented with a

good reason to imitate the modeled behavior. The use of traditional behaviorism promised or

imagined incentives, and vicarious models that reinforce the original intent of the model

(Bandura, 1986).

The use of Social Learning in advertising is pervasive. ―The constant flow of advertising

images of gender, types of persons, social classes, and other groups influence our social learning

process‖ (Roy, 1998). According to the same article, advertising plays an important role in social

reinforcement by using modeled behaviors to cultivate certain opinions, attitudes, and behaviors;

advertising not only sells products and services by providing individuals with coded information,

but indirectly suggests ways in which to understand the world (Roy, 1998).

A recent study found that print advertising is generally more informative than television

advertising, and the researchers concluded that the DTC television advertisements were not

doing a thorough job of meeting the FDA‘s fair balance requirements, particularly when

presenting information about the risks of the advertised prescription drug (Macias, Pashupati, &

Lewis, 2007). The fair balance requirement for DTCA is flexible and prohibits only ads that

convey a deceptive impression of the risk and benefits from the overall presentation of

information, rather than those that fail to achieve a mechanistic balance between risk and benefit

information because they do not present such information with identical emphasis" (FDA, 2007).

Fair balance requirements do not mandate that all side-effect information or potential

risks must be included in the advertisement, but that they must be in balance with the benefits

presented. These benefits and risks must also be comparable to those presented in advertisements

for other prescription drugs. This allows the industry the means of self-regulating its use of risk

4

information in DTCA, which may or may not satisfy the original requirements laid down by the

FDA (FTC, 2003).

It has been suggested that direct-to-consumer advertising has significantly increased

frequency of prescriptions of anti-depressant drugs in recent years (Hersey, 2004). ―The

increasing visibility of direct-to-consumer antidepressant advertising coincides with growing

numbers of antidepressant treatments‖ (Apfel, 2003). Several studies have noted how patients

complaining of depressive symptoms are more likely to receive a diagnosis and subsequent

medication by mentioning a specific advertisement to their doctors (Ackman & Glied, 2002).

Healthcare consumers in recent years have taken a more active role in determining what they are

prescribed, making their education regarding prescriptions drugs more important than is being

addressed by DTCA (Macias, et.al, 2007). In fact, according to a study using a sixty-eight

question survey regarding participant attitudes toward DTCA, a large portion of the group

(58.6%) believed that DTCA encourages consumers to take a more active role in managing their

prescriptions, while 27.6% felt that DTCA caused more confusion regarding the benefits and

harms of prescription drugs on the market and believed that the costs of DTCA outweigh its

benefits (Polen, et.al, 2009). The major purpose of this research is to explore what role, if any,

DTCA plays in the public‘s perception of depression and anti-depressants, as well as how DTCA

affects the college-age population.

5

Chapter 2: Review of Literature

There are many examples of DTCA influence on consumers in their interactions with

their physicians. A patient preparing for cataract surgery provided her nurse with a detailed list

of believed symptoms and preferred medications she wished prescriptions for upon discharge,

despite the fact that her physician was an opthamologist and was unqualified to prescribe

medications for high cholesterol, osteoporosis, and acid reflux. This example demonstrates that

DTCA may increase the likelihood of consumer self-diagnosis and complicate the balance

between physicians and patients (Salladay, 2007). In another example, a physician, Frey (2003),

describes a visit to his clinic by an eleven-year-old boy and his mother who demanded Lamisil,

based on an advertisement the boy had seen on television that showed fingernails that looked like

his own. When Frey prescribed a generic alternative considered to be just as effective, despite his

belief that the prescription was ultimately unnecessary, both the mother and the boy left

disappointed that their request for the brand-name medication had been denied (Frey, 2003).

Such examples demonstrate the influence that DTCA can have on consumer perceptions and

preferences for medications advertised most prevalently (Royne & Myers, 2008).

A study examining antidepressant advertisements analyzed the ―messages‖ embedded in

both imagery and words commonly used in advertisements. The researchers used semiotics and

frame analysis to examine the advertisements by applying Manning‘s (1987) five points of

analysis. According to the article, Manning‘s model suggests a comprehensive means of viewing

semiotic methodology (Bell, Kravitz, & Wilkes, 2000). Manning argues that semiotics

constitutes a model that is ―rooted in culture and seeks to identify the rules or principles that

guide signification, the process by which objects in the world communicate meaning‖ (Manning,

1987). The five points of analysis are used to analyze signs and what they symbolize and how

6

they relate to one another, second, how they are articulated, third, how they function socially,

fourth, to what degree they are integrated, and finally, to determine what, if any, are the

mythological components to their construction. The researchers were able to find that most anti-

depressant advertisements are framed as a bio-chemical issue and are highly skewed toward

women. Consumers are presented with a simplistic construction of a complicated medical

condition that cannot be bound by gender or biological components but is frequently a response

to ―social and cultural circumstances,‖ which encourages consumers to follow the advice of

advertisements rather than that of their own doctors (Bell, et.al, 2000).

One study found that the number of people diagnosed with depression and prescribed

anti-depressants was significantly higher during periods when direct-to-consumer advertising

(DTCA) spending was highest (cumulatively over 18.5 million). Patients diagnosed during this

period were 32% more likely to begin medication (Donahue, Berndt, Rosenthal, Epstein, &

Frank, 2004). In another study, a twenty-one item survey was sent to 604 prescribing clinicians

asking details about their prescription rates and how they were affected by DTCA. Most of the

respondents (87%) reported that DTCA prompted their patients to request inappropriate

medications and more than one in five of the reporting clinicians stated they experienced

difficulty persuading said patients to accept more appropriate prescriptions (Fortuna, Ross-

Degnan, Finkelstein, Fang, Campion, & Simon, 2008).

It is necessary to determine the extent advertising influences current views on depression

and current forms of medication and treatment if the communications and psychology

communities are to address the growing concerns regarding the relationship between increased

prescription of anti-depressants and prescription advertising (McKay, 2000). Medications like

anti-depressants for conditions with unclear diagnoses may be responsible for more potential

7

harm to consumers than other types of advertised medications. Depression is a more complicated

diagnosis with symptoms that aren‘t clear to someone who is not a trained professional; such

advertising is more likely to encourage unwitting consumers to seek treatment for a condition

from which they do not suffer (Royne & Myers, 2008).

Critics of DTCA claim that this form of advertising compromises the physician–

patient relationship and confuses patients by presenting promotional messages as educational

(Wolfe 2002). Proponents of this view also claim that DTCA increases consumer demand for

brands and more expensive medications rather than providing appropriate information needed to

make better health-care decisions (Mintzes 2002). Appel (2002) examined public perception of

DTCA, particularly regarding the anti-depressant Prozac, and found that patients with depression

may seek treatment because of Prozac advertisements. However, influence from the advertising

has in some cases prompted patients to choose brand-name anti-depressants over equally

effective generic drugs in the same classes that might be more appropriate. Experts also claim

that the medications presented in DTCA often give the appearance of being ‗‗new and

improved‘‘ over alternative treatments, while in many cases older and frequently less expensive

drugs may actually be the best treatment.

An‘s study (2008) conducted in the Midwest, found there was an effect on the perceived

prevalence of depression in subjects presented with anti-depressant DTCA. The study showed

that those with a higher recall for the advertising were more likely to estimate the prevalence of

depression as being higher than those who had lower recall. The study showed that when the

subjects were reminded where their information was taken from, its veracity was doubted and the

significant association was eliminated. The researchers concluded that while people are more

likely to remember the information presented in anti-depressant DTCA and make use of the

8

information, they will in most cases doubt its validity when reminded of its source. However, in

normal situations when the source is not highlighted, the subjects were more likely to adhere to

information presented in the DTCA, which argues for more cautious and thorough advertising.

Several studies dealing with the increased rate of prescription due to the claim of

increased direct-to-consumer advertising have found that most patients prescribed anti-

depressants by their regular physicians do not seek outside psychological treatment. According

to a recent study, evidence suggests that general practitioners often find making decisions and

diagnoses for depression problematic, but appropriate prescriptions are also difficult. It is

common practice to prescribe antidepressants for patients presenting symptoms of anxiety and

depression when that is not always the most practical solution (Hyde, Calnan, Prior, Lewis,

Kessler, & Sharp, 2005). A study investigating the success of drug therapy alone versus drug

therapy combined with psychoanalytical therapy found that the combined treatment was far more

successful than drug therapy alone, and in fact psychotherapy alone was extremely effective

(Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004).

Anti-depressant advertisements, like most commercial advertisements, are designed to

appeal to certain demographics and to play up the benefits of the product, while downplaying

negative aspects. According to Goldman and Montagne (1986), these kinds of advertising

techniques disrupt scientific discourse, certain types of social knowledge, and even discourage

professional debate regarding non-medicated treatment approaches to mental illnesses. Hersey‘s

(2004) exploratory study investigating how the portrayal of depression in pharmaceutical

advertisements has changed through the years since 1980 used content analytic and qualitative

methods to analyze advertisements. The researchers found that increased use of female models

dominated the advertisements through this time period, and that the advertisements portrayed an

9

increased number of ―recovered‖ patients. Commercials using these tactics were less likely to

focus on negative information, both in defining social interactions in the individuals portrayed,

and in the information given regarding treatment (Hersey, 2004).

A recent study (Frosch, Krueger, Hornik, Cronholm, & Bart, 2007) examined the makeup

of DTCA for prescription medications, including anti-depressant advertisements. A sample of

103 ads was coded for regularities such as symptoms, mechanism of the disease, causes or

prevalence of a condition, and subpopulations at risk. Then the ads were coded for how they

would appeal to consumers, including rational, positive emotional, negative emotional, humor,

fantasy, sex, and nostalgia appeals in their sample. Finally, the authors examined how the actors

portrayed the role of the medication advertised in their characters‘ lives. The authors noted that

while all of the advertisements included factual information about risks and side effects to meet

regulatory requirements, most of the ads limited the information to symptoms and the biological

nature of the disease or condition instead of focusing on the risks associated with the medication.

According to the article, only one-fourth of the sample examined presented a complete list of risk

factors for the specific medical condition and an even smaller eight percent of the ads included

specific information about the populations at risk for the conditions (Frosch, et.al, 2007).

The study also found that almost all the ads examined included positive emotional claims

regarding the use of the medication, and the majority of the negative emotional appeals made

typically showed the actor in a negative state prior to the use of the advertised medication,

followed by a positive appearance after the use of the medication, creating a sympathetic and

motivating presentation for consumers. More than half of the same advertisements included

information that claimed or implied that the characters in the advertisement regained control of

lost functions, abilities, and emotional connections after use of the medication, which creates an

10

equally compelling appeal for consumers exposed to DTCA for medication, especially anti-

depressants (Frosch, et.al, 2007).

While supporters of DTCA for medication may claim that there is little harm done to the

consumer by the advertising, due to the increased link between suicide and anti-depressants,

particularly in minors, many anti-depressant commercials, such as the popular Zoloft

advertisements, have been removed from broadcast (Rockoff & Wang, 2008), and company

websites have been forced to include efficacy statistics, as well as information about clinical

trials (Graber & Weckman, 2003), suggesting that the FDA does not agree. In February of 2004,

House Representative Henry A. Waxman criticized the FDA for allowing DTCA for prescription

medication to be misleading, giving consumers a skewed view of the medications‘ benefits and

risks. The FDA responded by releasing new guidelines for DTCA, but many critics are still

unsatisfied, claiming that the guidelines do not have enough application for television

advertisements and mainly focus on print and product labeling information, and that the material

is too complicated and loaded with technical jargon to be decipherable to anyone but a physician

(Young, 2004).

There are also examples of DTCA for prescription drugs being not only misleading but

false, including television commercials. For instance, Pfizer ran a series of commercials in 2007

advertising the cholesterol medication Lipitor with spokesman Dr. Robert Jarvik, who was touted

as the inventor of the artificial heart and was portrayed as an accomplished rower. Investigations

into claims made by the medical community revealed that not only was a body double used in

the rowing scenes that made up much of the commercial, but Robert Jarvik was not the sole

creator of the artificial heart and was in fact not a licensed physician at the time (Wedekind,

2008). The president of Pfizer was compelled to admit that the misleading way in which Robert

11

Jarvik was represented in the advertisements led to ―misimpressions and distractions,‖ ultimately

harming consumer perceptions regarding cardiovascular disease and its treatments. In January of

2008, The House Committee on Energy and Commerce's Subcommittee on Oversight and

Investigations started an investigation into "false and misleading statements and the use of

celebrity endorsements of prescription medications in direct-to-consumer advertising,‖ which

found that Pfizer was not the only company responsible for misleading advertisements, despite

recent regulations released by the FDA. The committee acknowledged that some of the most

popular DTCA for prescription medications practiced deceptive tactics (Dingell, 2008).

A number of recent advertisements have not been for any specific anti-depressant drugs,

but have been generalized advertisements about depression from drug companies directing

viewers to websites with more information on treatment. Graber and Weckman (2003) examined

the websites of anti-depressants and their companies for a varied and thorough presentation of

both the benefits and the risks of anti-depressant treatment found that out of nine websites, three

contained anecdotal information designed to make the practice of drug treatment seem more

common to the potential customer. Only four of the websites mentioned other drug therapy as

treatment, and only one mentioned the trade names of other drugs. None of the websites

mentioned drug costs; only one had efficacy statistics for the drug. While all of the websites

mentioned at least one adverse effect, only one site had percentage rates for adverse effects, and

none of the sites listed all adverse effects found in clinical trials. Graber and Weckman

concluded that information about anti-depressants found on their own company websites is

faulty, incomplete, and makes it difficult for consumers to compare drugs and other methods of

treatment.

12

There are few studies that deal directly with the attitudes of the population toward

depression. The incorporation of this measure should be essential in determining the prevalence

and seriousness of depressive disorders in the U.S.; the general lack of knowledge regarding

depression and its treatments adds to the dilemma (Goldney et al., 2001). Studies in this field are

limited. Most deal with the diagnosis and treatment of depression, not the general perception of

the disorder. One study measured mental health literacy, and found that only thirty-nine percent

of a community sample correctly labeled depression (Goldney et al., 2001). Though this study

did not examine the effect of advertisements on public opinion, it does give broad measure of

perception, and provides a basic idea of how poorly informed people are on the subject.

Supporters of pharmaceutical advertising argue that the advertisements are not meant to

mislead consumers, but to inform regarding disorders and the prescription drugs used to treat

them. Pharmaceutical companies claim that DTCA is meant to encourage consumers to talk to

their doctors about the drugs and is not meant to influence purchasing behavior (Holmer, 1999).

Supporters argue that DTCA can actually improve public health and knowledge about diseases

that are frequently misunderstood or misdiagnosed, and will encourage consumers to seek out

other sources of information, whether from friends, family, doctors, or even other popular media

(Royne & Myers, 2008). According to a review of current literature regarding DTCA, it was

suggested that proponents of DTCA claim that the increased availability of complex and

sometimes inaccessible information is a significant benefit for the general public, giving them

the opportunity to make informed decisions about their health care. Supporters also claim that

advertising of medications encourages consumers to take a more active role in personal health

and provides necessary information to help them seek medical attention for conditions that might

otherwise go unidentified and untreated (Royne & Myers, 2008). It is also acknowledged that

13

DTCA is not the only source of information on popular medications; while DTCA sometimes

provides a catalyst for consumers to seek information about a particular medication, many

consumers have existing knowledge regarding popular medications based on information from

family members, friends, or earlier discussions with physicians. DTCA supporters conclude that

while DTCA is an important informative tool for the general public, it is by no means the only

source of information (Royne & Myers, 2008).

Huh and Becker (2005) found that especially ―older and less educated consumers benefit

from prescription drug advertising since they are more likely to be ready to communicate with

their doctors.‖ The research also suggested that women who view DTC prescription advertising

are more likely to seek out information independently and be able to communicate more

effectively with their doctors (Huh & Becker, 2005).

A study conducted by Limbu and Torres (2009) examined the difference in effectiveness

of DTC prescription advertising with consumers who were considered either low or high

involvement. Those with low involvement were considered to have less interest and concern in

an object or product before exposure to advertising, while those with high involvement displayed

higher levels of interest and concern in an object or product before exposure. The researchers

argued that consumers with high involvement were more likely to approach their doctors about

the prescription drug advertised than those with low involvement. Based on their findings,

Limbu and Torres suggested that persuasive DTCA is more likely to encourage high

involvement consumers to communicate with doctors about an advertised drug; the researchers

concluded that the advertising would mainly appeal to those who would already be susceptible to

persuasive advertising (Limbu & Torres, 2009).

14

Herzenstein, Misra, and Posavac (2005) claimed that consumers‘ attitudes regarding DTC

prescription advertising were neither favorable nor unfavorable, but that attitudes were related to

whether consumers independently sought out further information about the drug, asked their

doctors about the drug, or were likely to seek out relevant information from a friend or local

pharmacist. Consumers who rely on interpersonal aid and mass media in discovering health

information tend to have more positive attitudes regarding DTCA (Lee, Salmon, & Paek, 2007).

Oncology Nurse Practitioners (ONPs) were surveyed regarding their opinions on DTC

prescription advertising. While they were found to have mixed opinions regarding the practice,

most did not believe that they were heavily influenced by relevant advertising with regard to

patients‘ prescriptions. The surveyed ONPs also suggested that patients who asked about specific

medications based on DTCA were generally interested in the veracity of the information

presented and it did not seem to have a significant effect on their requests for specific medication

(Viale & Yamamoto, 2004).

Depressive disorders are most common in adults, and one of the major populations of that

community is college students. As part of the population getting their general information on

depression from commercials and magazine articles, according to the APA, the number of

unreported cases of depression is growing. Abernathy and Adams-Price (2006) compared older

versus younger adults‘ ability to remember and comprehend drug information. They found that

younger adults had a greater increase in their knowledge of the drugs presented in the advertising

condition. For college students dealing with the extra stressors of college life, depression is a

common problem and they are likely to seek out treatment; however, many may be biased in

their attitudes toward the disease, as well as its treatment due to the increase in DTCA of anti-

depressants (Pilcher, 1998).

15

The college age population is essentially important as it is a milestone growth into

adulthood from adolescence (Persi, 1997). For students faced with high stress, social behavior

expectancies, and absence from family, depression can be triggered by an already existing

tendency to the disorder (Pilcher, 1998). During college years, many young adults are

introduced to new developmental tasks and responsibilities, which are often linked to mental

distress (Apfel, 2003). One particular case study noted the difficulty experienced by teenagers

suffering from emotional disorders in making the transition to adulthood (Gilbody & Davis,

1999). A study conducted through the 2007 Annenberg National Health Communication survey

investigated the impact of exposure to DTCA for prescription anti-depressants and anti-anxiety

medications on public perception and opinion regarding treatment for youth experiencing

depression or anxiety. The survey was distributed to a sample group of adults who were exposed

to current DTCA for anti-depressants and found that those among the group who did not have

previously negative attitudes towards DTCA were more likely to prefer the medications

advertised in the treatment of youths with depression or anxiety, while those who had previously

expressed negative perceptions of DTCA were less likely to respond positively to the

medications advertised (Martinez & Lewis, 2009). Because of the delicate nature of mental

illnesses such as depression, it is imperative to be able to accurately identify depression and seek

appropriate treatment, which may or may not include a popularly advertised medication, for

which a general practitioner may or may not be sufficient (Gilbody & Davis, 1999).

The influence of advertising on college students is as prevalent as with the general adult

public. Depression has been an issue of growing concern for college students (Apfel, 2003). A

longitudinal study at a university counseling center found that the number of students seeking

help for depression doubled from 1988 to 2001 (Benton, Robertson, Tseng, Newton, & Benton,

16

2003). In addition, anti-depressants have become the most popular form of treatment prescribed

despite availability of many other alternatives (Jureidini & Tonkin, 2006).

Students are more likely to confuse transitional and typical distress associated with age,

stress, and isolation with depression; the common phrase found in drug advertisements ―ask your

doctor if this [medication name] is right for you,‖ encourages students to seek out drug therapy

rather than attempt less aggressive methods (Kadison, 2005). Family and friends exposed to

these advertisements may also add to the impression of students experiencing depression by

suggesting that ―symptoms‖ exhibited by students are indicators of a mental disorder (Kadison,

2005). Some students are also developing the view that antidepressant medication will maximize

school performance, neutralize anxiety, or provide a mood boost. While it is possible that

increased visibility and awareness of depression may reduce the public stigma attached to

common mental disorders, it also suggests that the advertisements are a ―magic bullet‖ for young

adults‘ complex and varied problems (Kadison, 2005).

In fact, a study conducted at the University of Wyoming examined college students‘

perceptions of depression when given the typical explanation found in prevalent advertising that

depression is a chemical imbalance versus a more accurate biopsychosocial explanation. The

study found that students who accepted the chemical imbalance explanation were more likely to

view drug treatment more favorably than psychotherapy, while students who accepted the

biopsychosocial explanation were more inclined toward therapy and less favorable about drugs.

The findings suggest that commercials that use the chemical imbalance explanation are more

likely to influence consumers and college students in particular to view prescription drug

treatments as more effective than therapy, which is harmful to the overall view of depression and

its treatment (Deacon & Baird, 2009).

17

In order to better understand college students‘ perception and use of widely advertised

prescription medications, one study surveyed over four-hundred students from three separate

institutions regarding their use of advertised medications, how much attention they paid to

advertisements, their level of communication with physicians regarding the medications, and

their perceptions of the conditions treated by the advertised medications (Burak & Damico,

2000). The researchers found that the majority of the students surveyed used at least one of the

advertised products they were questioned about and most students did not discuss alternative

pharmaceutical products with their doctors, nor did they discuss the conditions with their

doctors. As Burak and Damico claim, since young people, including college students, are more

likely to take more than the recommended dosage or take medication for purposes other than

intended, or even in combination with other drugs, there is concern that advertising, especially if

it is faulty or misleading might encourage students to seek out unnecessary medication or use

their prescriptions to adverse reactions. According to the article, young adults are more likely to

self-medicate and are generally less open with their physicians, making them particularly

susceptible to prevalent advertising that describes their perceived symptoms and treatment in one

commercial (Burak & Damico, 2000).

A study conducted to determine the effectiveness of anti-depressant advertising on

undergraduates in a university separated participants into two groups: a scientific study condition

and an advertisement condition. Based on the Beck Depression Inventory used by the

researchers, 40% of the female participants in the advertisement condition believed they were

experiencing depression after being exposed to the advertisement, as opposed to 6% in the

scientific study condition. The results suggest that female participants in the advertisement

condition were more likely to believe that they had depression, that depression required

18

treatment with anti-depressants, and were likely to suggest anti-depressant treatment to family

and friends (Frankenberger, Frankenberger, Peden, Hunt, Raschick, Steller, & Peterson, 2004).

As with any disease, those suffering from depression need to be aware of symptoms and

treatment options. Recently, the increase in medication advertisement, as well as patient

demand, has begun to influence doctors‘ decisions (Schwenk, 2005). For a single episode of

depression, an average physician will prescribe anti-depressants for up to nine months without

requiring a psychological workup (Demytteneaere, Bruffarets, Albert, Mesters, Dewe,

Debruyckere, & Sangeleer, 2004). Since the 1980s it has become routine to prescribe such drugs

as a management of depression; however, the negative effects are beginning to show in long-

term users (Nierenberg, 1999). It is crucial to correctly identify and treat depression, not only to

ensure attention from those actually suffering from a major depressive disorder, but also to

prevent any negative side effects or even suicide in those being treated unnecessarily.

There is a need to expand upon these studies in the realm of college students‘ perception

of depression (Frankenberger, et. al., 2004). It is not pertinent to this study to screen for

depression or discuss in depth the symptoms, but only to ascertain the general perceptions of the

disease. The influence of advertisements and incorrect information is also of interest; it is

important to see if such methods of communication are harmful to the general population‘s

perception of depressive disorders.

The following study was designed to determine how much of an effect, if any,

advertisements have on college students‘ perceptions of depression and anti-depressants. As

there is very little research on this subject pertaining to college students and young adults (Royne

& Myers, 2008), the researcher intends to investigate how DTCA affects beliefs and perceptions

on the effects of anti-depressants, the risks associated with them, and overall knowledge about

19

depression after exposure to a manufactured broadcast advertisement. The researcher is

interested in determining whether the questionable material being presented in television DTCA

is not only influencing treatment preferences, but is also adding to the already confused

perceptions of depression, or if it is simply adding to the collective knowledge regarding

depression and its treatment.

For the purposes of this study, the following questions will be researched:

RQ1:Will sampled Marshall University students learn claims from an example of DTC

medication advertising?

RQ2:Will the advertisement have an effect on their perceptions of depression and its

treatment?

RQ3:Will misleading information buried in an advertisement influence students‘

responses regarding informational questions about depression and treatment?

RQ4: Based on Bandura‘s Social Learning Theory which states that individuals learn

behavior from models presented in a stimulating and accessible manner (Bandura, 1997),

will students learn faulty information from a constructed advertisement?

The researcher anticipates the effects of incorrect or misleading information presented in

commercial form will significantly alter participants‘ perceptions of depression and anti-

depressants, and will create a link between DTCA and specific ideas about medication.

20

Chapter Three: Methods

The researcher conducted an exploratory study on the effects on Marshall University

students‘ perceptions of depression and treatment by creating two advertisement conditions and

maintaining a control group in a single exposure experiment.

Respondents

In order to provide a pool of participants of the correct age and interests, the participants

were drawn from both graduate and undergraduate Marshall University classes as a cross-section

of the university‘s population. The researcher sent requests to several professors in different

departments at Marshall University for the use of time during classes to conduct the study, and

with permission from cooperating instructors, the researcher was able to draw a convenience

sample of 90 participants, with 30 participants in each of the three test groups. There was no

incentive for participation; participants were recruited on a voluntary basis. Students in

psychology classes and psychology majors were excluded from the study in order to eliminate

possible bias; the researcher believed due to the psychology curriculum there was a possibility

for prior knowledge of depression and treatments that would alter participants‘ responses and

therefore render the results invalid. The participants were treated in accordance with the

American Psychological Association ethical guidelines, as well as Marshall University‘s

Institutional Review Board‘s requirements.

Apparatus

The researcher determined which anti-depressants were among the top-searched

medications on the Internet (Newell, 2008), the researcher viewed advertisements for each of the

medications including Effexor, Cymbalta, Lexapro, and Paxil, to analyze the common

components used in the DTCA. After visiting the websites for the medications, it was clear that

21

the television commercials would be most representative of DTC prescription advertising, due to

the length of the ad and the visual aspect of video and music, which was not found on each

website. Each commercial was recorded from television and viewed four times. The researcher

determined a pattern to certain elements that could be reproduced for the purposes of the study:

first, the portrayal of actors in depressed or negative poses, usually with slow music and dim

lighting in the background; second, a basic description of depressive symptoms including the

loss of interest in activities, anxiety, suicidal thoughts, etc.; third, the commercials claimed that

depression is caused by a chemical imbalance; finally, the commercials gave a brief description

of the risks associated with the medication, and then showed the actors in a more positive setting,

recovering lost abilities or relationships, and played upbeat music with brighter lighting in the

background, in many cases, placing the actors in a bright outdoor setting.

Based on these common components, the researcher created two versions of a

commercial encouraging the general use of anti-depressants. The commercial followed the basic

format of the researched anti-depressant advertisements; since the advertisements reviewed were

between 30 seconds and 120 seconds, the manufactured commercial was one-minute long and

featured several different actors of both genders ranging from college-age to middle-age. The

commercial opened with basic information about depression similar to that in the reviewed

commercials and then shifted into information about anti-depressants and how they improve

depressive symptoms (see Figure 4.1). In the first half, the actors were shown experiencing a loss

of enjoyment of activities such as playing with a dog, frustration at work, marital difficulties, and

apathy; in congruence with the reviewed advertisements, the music was slow and the lighting

was dim. During this portion, the information about depression was revealed, including the

common assertion that depression is caused by a chemical imbalance. The advertisement then

22

transitioned into the positive segment, portraying the actors enjoying activities again, smiling and

displaying happiness in relationships; the lighting was also brighter and most of the scenes were

shown out of doors with more upbeat music playing in the background, as was described in the

study that examined the negative and positive emotional appeals in DTC medication advertising

(Frosch, et.al, 2007).

Due to the arguable presence of misleading or false information in prevalent medication

advertising, such as the previously described example of Lipitor, and the concerns raised by the

government about misleading prescription DTCA and the FDA‘s slow response to addressing

inconsistencies and misleading information in DTC television advertisements (Young, 2004), the

researcher chose to create a version of the commercial with three inaccurate or misleading

statements regarding anti-depressants, their use, and possible side effects. The incorrect

statements were based on information in an article that investigated common misconceptions and

perceptions of depression and antidepressants. The article suggests that participants frequently

believed falsely that: 1. Anti-Depressants will not cause withdrawal symptoms when ceased

suddenly; 2. Depression causes suicide; 3. Depression can be diagnosed in one doctor‘s visit, and

treatment can be decided in the same visit (Hegerl, Althaus, & Stefanek, 2003). All of the

information used to construct the commercial as well as the survey was taken from articles on the

American Psychological Association (APA) website. The version of the commercial without

misleading statements was created in the same format, but omitted the incorrect or misleading

information. The commercials were presented to participants in two advertising conditions

during classes, with the permission of the instructors. Due to class sizes, which did not exceed 50

students in any case, the researcher was able to show the participants in each class either the

misleading commercial or the correct commercial using a DVD player on a laptop computer and

23

a projector, depending on the equipment available at the testing locations, which were in

Marshall University classrooms. In classrooms that did not have a projector available, the

students were asked to watch the DVD on the screen of the laptop.

The researcher developed a 15-question survey to measure the participants‘ perceptions

of depression and anti-depressants, to be taken following the viewing of the commercial. The

survey opened with brief demographic information to obtain the participants‘ age, major area of

study, and gender; the researcher used the information only to ensure that no surveys taken by

psychology majors were used. The questions were developed from statements frequently made in

the reviewed anti-depressant commercials, the manufactured commercial, and information from

the APA website. The survey was set up as a true/false condition; participants were presented

with a statement that they could either qualify as true or false based on their own perceptions.

Questions four (Anti-depressants will not cause withdrawal symptoms when ceased abruptly),

twelve (Depression causes suicide), and fifteen (Depression can be diagnosed in one doctor‘s

visit, and treatment can be decided in the same visit), corresponded directly to the false

statements in the commercial and were designed to be a direct measure for the accuracy of

participants‘ knowledge about depression and anti-depressants. Other questions were taken from

the correct information in the commercial, and the remaining questions were taken from current

scientific information, as found on the APA website. Each question was formulated to

reasonably simulate information that might be found in actual DTCA without being a direct

quotation in order to ensure that the participants were only responding to the researcher‘s

manufactured commercial.

Procedure

24

There were three test groups in the experiment: Group 1, an experimental group that

viewed the commercial with the false statements and then completed the survey directly after a

single exposure to the advertisement; experimental Group 2 viewed the version of the

commercial without the false statements and then completed the survey directly after a single

exposure to the advertisement; the control group (Group 3) completed the survey without

viewing either commercial.

Commercial w/out

misleading

information viewed

Commercial with

misleading

information viewed

Survey Taken

Group 1

(Experimental)

X X

Group 2

(Experimental)

X X

Group 3

(Control)

X

The participating classes were randomly assigned to one of the experimental groups or

the control group ahead of time.

Respondents were not informed beforehand that the commercial did or did not contain

misleading statements. Respondents viewed the commercial as it played on the projected screen

or the laptop screen. When the commercial ended, the lights were brought back up and the

respondents completed the survey following instructions to answer the questions honestly and in

accordance with their beliefs about the material presented. When the groups completed the

surveys, the researcher passed out the debriefing form (see figure 1.3), and thanked them and the

instructor for their time. Respondents in the test group were informed during debriefing that

25

there had been false statements in the advertisement and were told what the false statements

were. The same procedure was followed with respondents in experimental Group 2.

The control group (Group 3) also signed consent forms and completed the questionnaire.

The group was debriefed, but was not exposed to any advertising. The control group helped to

ensure that differences in the responses of the experimental groups could be attributed to

information presented in the advertising condition, and did not come from prior or outside

knowledge.

Following the completion of the experiment, all participants were debriefed according to

APA and Marshall University IRB standards.

26

Chapter Four: Results

The results are as follows:

Question 1: Depression is a mental disorder. SUMMARY F-ratio 0.946092

Groups Count Variance Group 3 30 0.152116 Group 2 30 0.21164 Group 1 30 0.126984

Question 2: Depression has genetic traits. SUMMARY F-ratio 1.216738

Groups Count Variance Group 3 30 0.22619 Group 2 30 0.152116 Group 1 30 0.238095

Question 3: Women are more likely to suffer from a depressive disorder. SUMMARY F-ratio 0.065116

Groups Count Variance Group 3 30 0.189655 Group 2 30 0.169951 Group 1 30 0.169951

Question 4: Antidepressants will not cause withdrawal symptoms when ceased. (Test Question) SUMMARY F-ratio 1.385417

Groups Count Variance Group 3 30 0.096059 Group 2 30 0.169951 Group 1 30 0.206897

Question 5: Someone suffering from Depression is likely to be irritable and aggressive. SUMMARY F-ratio 0.070707

Groups Count Variance Group 3 30 0.169951 Group 2 30 0.147783 Group 1 30 0.169951

27

Question 6: Depression is a disease. SUMMARY F-ratio 0.179487

Groups Count Variance Group 3 30 0.258621 Group 2 30 0.251232 Group 1 30 0.258621

Question 7: Depression is caused by a chemical imbalance in the brain. SUMMARY F-ratio 0.150538

Groups Count Variance Group 3 30 0.066502 Group 2 30 0.066502 Group 1 30 0.096059

Question 8: Antidepressants are non-habit forming. SUMMARY F-ratio 9.303226

Groups Count Variance Group 3 30 0.034483 Group 2 30 0.251232 Group 1 30 0.096059

Question 9: Depression can be a chronic problem. SUMMARY F-ratio 0.835821

Groups Count Variance Group 3 30 0.034483 Group 2 30 0.096059 Group 1 30 0.034483

Question 10: Depression can have physical symptoms, such as headaches, digestive disorders, and chronic pain. SUMMARY F-ratio 0.525

Groups Count Variance Group 3 30 0.034483 Group 2 30 0.066502 Group 1 30 0.096059

28

Question 11: People suffering from Depression tend to suffer from a sleeping disorder, such as hypersomnia or insomnia. SUMMARY F-ratio 0.133333

Groups Count Variance Group 3 30 0.096059 Group 2 30 0.096059 Group 1 30 0.066502

Question 12: Depression causes suicide. (Test Question) SUMMARY F-ratio 3.635659

Groups Count Variance Group 3 30 0.206897 Group 2 30 0.169951 Group 1 30 0.258621

Question 13: Antidepressants can have physical side-effects. SUMMARY F-ratio 1.484848

Groups Count Variance Group 3 30 0.096059 Group 2 30 0 Group 1 30 0.066502

Question 14: Depression is a common problem; most people will experience or come in contact with depression at some point during their lives. SUMMARY F-ratio 0.0875

Groups Count Variance Group 3 30 0.147783 Group 2 30 0.123153 Group 1 30 0.123153

Question 15: Depression can be diagnosed in one doctor‘s visit, and treatment can be decided in the same visit. (Test Question) SUMMARY F-ratio 0.755187

Groups Count Variance Group 3 30 0.189655 Group 2 30 0.23399 Group 1 30 0.169951

29

Based on a 0.05 level of significance, the advertising condition did not have a significant

effect overall. The results of an Analysis of Variance (ANOVA) performed on correct responses

to question twelve, the second of the false information questions, showed a significant link

between the performance of the false advertising condition and the control group with a

significance level of 0.03. The responses to the other questions taken from the false statements

in the advertisement did not demonstrate a significant link.

There were four other questions that directly corresponded to truthful information in the

commercial; question three, question seven, question eight, and question fourteen. There was no

significant difference between the test group responses in any of the questions except for

question eight (Antidepressants are non-habit forming). The responses in both advertising

conditions differed significantly from the survey condition with a level of 0.0002. The responses,

however, were the opposite of the information presented in the commercial, displaying a

perception that antidepressants are habit-forming, which, according to the FDA (2007), is not

correct. There does not appear to be any concrete explanation for the results. Overall, the results

did not reflect the researcher‘s anticipation that the advertising condition would have a

significant effect on participants‘ responses. The two instances of significant difference are likely

not related to the advertising condition, but are due to extraneous factors.

30

Chapter Five: Discussion

The results of the current study do not demonstrate a significant link between the

advertisement conditions and surveyed Marshall University students‘ perceptions of depression

and anti-depressants. Accuracy for questions four and fifteen were not significantly lower for

Group 1 than for the control group, which suggests that the advertisement did not affect the

participants‘ responses. For question twelve (depression causes suicide), accuracy did differ

significantly with a 0.03 level of significance; however, because this was the only question in

which there was a significant difference among the three test groups, it may be inferred that there

were other variables contributing to the results, and the responses were not solely based on the

information presented in the advertisement condition.

Overall, the results did not support the expectation that the advertising condition would

significantly alter the perceptions of participants regarding depression and its treatment. The

sampled Marshall University students were not influenced by the example provided of DTC

medication advertising, and it did not appear to have any significant effect on their perceptions of

depression and its treatment. The misleading information was correctly identified as false by the

respondents, which suggests that the respondents did not base their perceptions solely on the

advertisement, but were influenced by outside sources or prior knowledge. In this case, the

participants did not model behavior based on the advertisement, which also supports the

possibility that they had outside information on the subject presented.

As displayed in Figure 2.1., the results for question twelve (Depression causes suicide)

show that it is possible for anti-depressant advertisements with incorrect information to influence

participants‘ perceptions of depression and anti-depressants, or that there is a general perception

31

that depression causes suicide. It is also possible that the wording of the question or information

in the commercial was misinterpreted by the respondents since none of the other misleading

statements appeared to influence responses significantly. The correct responses to the questions

corresponding to the other incorrect statements suggests that while some respondents may be

influenced to some degree by advertisements, they are also being influenced by information from

other undetermined sources. This conclusion is supported by the results for question eight

(Antidepressants are non-habit forming), which directly corresponded to correct information in

the advertisement; however the participants in the advertising conditions overwhelmingly

disagreed with the information. While the researcher can offer no definite explanation for the

results, it may be inferred that the participants had outside information or prior knowledge that

encouraged them to contradict the factual statement in the commercial.

The results of this study neither support nor contradict existing research that suggests

advertising, particularly DTCA, can have a significant effect on viewers, and that advertisers

should exercise caution in their selection of information for inclusion or exclusion in their

advertising (Graber & Weckman, 2003). A recent study argues that both ―proponents and

opponents‖ of DTCA of prescription drugs assume that the ads increase prescriptions and

awareness of diseases and treatments (Holmes, 2008). A study conducted by Michael Law of

Harvard Medical School in Boston showed DTCA from the U.S. to viewers in Canada, where

DTCA is prohibited. The study found that only one of three medications advertised saw an

increase in prescription rate, and the effects only lasted for a few months. These findings suggest

there may be a relationship between DTCA and perceptions of depression, but there are other

sources of information that may contribute to the public‘s attitude.

32

The researcher had anticipated that the misleading information in the advertisement

presented to Group 1 would significantly alter participants‘ perceptions of depression and

antidepressants, and would demonstrate a relationship between DTCA and specific ideas about

medication. The results of this study did not support the expected outcome, but several

unexplained results, including the significant link between the advertising condition and

participants‘ responses to question twelve (Depression causes suicide) and the participants‘

disagreement with correct information in question eight (Antidepressants are non-habit forming)

suggest that further research might generate different results.

33

Chapter Six: Limitations and Recommendations

As there is very little existing literature dealing specifically with the views and

perceptions of college students and young adults regarding depression and anti-depressants and

how they are affected by direct-to-consumer advertising (Royne & Myers, 2007), this study

could be replicated in other university situations, as well as in adult groups. If the study were to

be investigated further, different media with the false information could be used, including a

manufactured print ad and several different advertisements. This study used a single exposure in

the advertising conditions; a future replication would benefit from having multiple exposures

over a period of time for greater likelihood of retention. A larger sample would be more

effective, such as from several different universities in the region, or at least a wider selection of

students from the university chosen.

Also, the use of focus groups could be a more effective means of measuring the influence

of advertisements; having the participants in a more controlled environment with multiple

exposures to varying types of advertising conditions could also affect the results differently. The

testing sites for this study were Marshall University classrooms with large groups of participants;

a more intimate setting with groups of no more than fifteen might be more effective and provide

fewer distractions for participants. Also, in future research, the survey should include questions

about where participants believe they obtain most of their existing knowledge about depression

in order to determine what outside sources might be affecting their responses in the advertising

conditions.

As a preliminary review before conducting the experiment, a future investigation might

wish to survey the sample group regarding general information readily available about the

subject matter before constructing the manufactured advertisement and survey in order to prevent

34

cross-contamination from outside sources. A future investigation into the acceptance of both

correct and incorrect information in advertising may also provide insight into how the

information is processed and perceived by the general public.

When researching popular commercials for patterns in DTCA, a future investigation

should employ a panel of at least three members in determining the common elements. For the

purposes of this study, the researcher was the only individual identifying patterns, and a future

study would benefit from multiple viewers in order to identify the optimum patterns and

elements; it is a limitation of this study that the researcher was the sole determinant.

35

References

Ackman, D., Glied, S. (2002). Direct-to-consumer marketing: Commentary. New

England Journal of Medicine, 346, 2011.

An, S. (2008). Antidepressant direct-to-consumer advertising and social perception of the

prevalence of depression: Application of the availability heuristic. Health

Communication, 23, 499-505.

Apfel, J. L. (2003). Depression and its treatments: A college sample. Journal of College

Student Psychotherapy, 18, 67-81.

Appel, L.J. (2002). The verdict from ALLHAT-thiazide diuretics are the preferred initial

therapy for hypertension. Journal of the American Medical Association, vol. 288, 3039–

3042.

Bandura, A. (1977). Social learning theory. New Jersey: Prentice-Hall.

Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ:

Prentice-Hall.

Bell, R. A., Kravitz, R. L., & Wilkes, M. S (2000). The educational value of consumer-

targeted prescription drug print advertising. The Journal of Family Practice, 49, 1092-

1098.

Benton, S. A., Robertson, J. M., Tseng, W., Newton, F. B., & Benton, S. L. (2003).

Changes in counseling center client problems across 13 years. Professional

Psychology: Research and Practice, 34, 66-72.

Burak, L., & Damico, A. (2000). College students‘ use of widely advertised medications.

Journal of American College Health, 49, 118-122.

Deacon, B. & Baird, G. (2009). The chemical imbalance explanation of depression:

36

Reducing blame at what cost? Journal of Social and Clinical Psychology, 28, 415-435.

de Jonghe, F., Hendriksen, M., van Aalst, G., Kool, S., Peen, J, Van, R., van den Eijnden,

E., & Dekker, J. (2004). Psychotherapy alone and combined with

pharmacotherapy in the treatment of depression. British Journal of Psychiatry,

185, 37-45.

Demytteneaere, K., Bruffarets, R., Albert, A., Mesters, P., Dewe, W., Debruyckere, K., &

Sangeleer, M. (2004). Development of an antidepressant compliance

questionnaire. Acta Psychiatrica Scandinavica, 110, 201-207

Dingell, J. D., Chairman of the House Committee on Energy and Commerce

Subcommittee on Oversight and Investigations (2008). Letter to Pfizer, Inc. Chairman of

the Board and CEO Kindler in regard to concerns about celebrity endorsements of

prescription medications in direct-to-consumer advertising. January 7.

Donahue, J.M., Berndt, E.R., Rosenthal, M., Epstein, A.M., & Frank, R.G. (2004).

Effects of pharmaceutical promotion on adherence to the treatment guidelines for

depression. Medical Care, 42, 1176-1185.

Fortuna, R., Ross-Degnan, D., Finkelstein, J., Fang, Z., Campion, F. X., & Simon, S. R.

(2008). Clinician attitudes towards prescribing and implications for intervention in a

multi-specialty group practice. Journal of Evaluation in Clinical Practice, 14, 969-973.

Frankenberger, K., Frankenberger, W., Peden, B., Hunt, H., Raschick, C., Steller, E., &

Peterson, J. (2004). Effects of information on college students‘ perceptions of anti-

depressant medication. Journal of American College Health, 53, 35-40.

Frey, J. (2003). Selling drugs to the public: Should the UK follow the example of the US?

The British Journal of General Practice, 52, 170–171.

37

Frosch, D. L., Krueger, P. M., Hornik, R. C., Cronholm, P. F., & Barg, F. K. (2007).

Creating demand for prescription drugs: A content analysis of television direct-to-

consumer advertising. Annals of Family Medicine, 5, 6–13.

Gilbody, S.M., & Petticrew, M. (1999). Rational decision making in mental

health: the role of systematic reviews. Journal of Mental Health Policy &

Economics, vol. 2, issue 3, 99-106.

Goldman, R. & Montagne, M. (1986). Marketing "mind mechanics": Decoding

antidepressant drug advertisements. Social Science & Medicine, vol. 22, 1047-1058.

Goldney, R. D., & Fisher, L. J, & Wilson, D. H. (2001). Mental health literacy: an

impediment to the optimum treatment of major depression in the community.

Journal of Affective Disorders, 64 (2), 277-284.

Government Accountability Office. (2006). Prescription drugs: Improvements needed in

FDA‘s oversight of direct-to-consumer advertising: GAO-07–54. GAO Reports, 1–52.

Graber, M.A. & Weckmann, M. (2002). Pharmaceutical company internet sites as

sources of information about antidepressant medications. CNS Drugs, 16, 419-423.

Hegerl, U., Althaus, D., & Stefanek, J. (2003). Public attitudes towards treatment of

depression: Effects of an information campaign. Pharmacopsychiatry, 36, 288-291.

Hersey, B. (2004). Changing representations of depression in pharmaceutical advertising:

1980—2000. The Sciences & Engineering, 65, 31-62.

Herzenstein, M., Misra, S., & Posavac, S. (2005). How consumers‘ attitudes toward

direct-to-consumer advertising of prescription drugs influence ad effectiveness, and

consumer and physician behavior. Marketing Letter, 15, 201-212.

Holmer, A. F. (1999). Direct-to-consumer prescription drug advertising builds bridges

38

between patients and physicians. Journal of the American Medical Association, 281, 380-

382.

Holmes, B. (2008). Drug ads may not increase prescriptions. New Scientist, 199 (2672),

10.

Huh, J. & Becker, L. B. (2005). Direct-to-consumer prescription drug advertising:

understanding its consequences. International Journal of Advertising, 24, 441-466.

Hyde, J., Calnan, M., Prior, L., Lewis, G., Kessler, D., & Sharp, D. (2005). A qualitative

study exploring how GPs decide to prescribe antidepressants. British Journal of General

Practice, vol. 55, 755-762.

Jureidini, J., & Tonkin, A. (2006). Overuse of antidepressant drugs for the treatment of

depression. CNS Drugs, 20, 623-632.

Jureidini, J., Mintzes, B., & Raven, M. (2008). Does direct-to-consumer-advertising of

anti-depressants lead to a net social benefit? Pharmacoeconomics, 26, 557-566.

Kadison, R. (2005). Getting an edge: use of stimulants and antidepressants in college.

New England Journal of Medicine, 1089-1091.

Khanfar, N., Clauson, K., Polen, H., & Shields, K. (2008). Self-reported influence of

television based direct-to-consumer on patient seasonal allergy and asthma medication

use: An Internet survey. Current Therapeutic Research, 69, 130-141.

Lee, B., Salmon, C. T., & Paek, H. (2007). The effects of information sources on

consumer reactions to direct-to-consumer (DTC) prescription drug advertising: A

consumer socialization approach. Journal of Advertising, 36, 107-119.

Limbu, Y., & Torres, I.M. (2009). The effects of involvement and ad type on attitudes

39

toward direct-to-consumer advertising of prescription drugs. Journal of Health & Human

Services Administration, 32, 51-82.

Macias, W., Pashupati, K., & Lewis, L.S. (2007). A wonderful life or diarrhea and dry

mouth: Policy issues of direct-to-consumer drug advertising on television. Health

Communication, 22, 241-252.

MacPherson, R. & Robson, E. (1994). How do clinicians choose antidepressants?

Psychiatric Bulletin, 18, 597-599.

Manning, P. K. (1987). Semiotics and fieldwork. Newbury Park, CA: Sage Publications.

Martinez, L. & Lewis, N. (2009). The role of direct-to-consumer-advertising in shaping

public opinion surrounding prescription drug use to treat depression and anxiety in youth.

Journal of Health Communications, 14, 246-261.

McKay, D. (2000). Stigmatizing pharmaceutical advertisements. British Journal of

Psychiatry, 177, 467-468.

Mintzes, B. (2002). For and against: Direct to consumer advertising is medicalising

normal human experience. British Medical Journal, 324, 908–909.

Newell, J. (2008). Top 12 drugs most searched on the Internet. HealthNews.com.

Retrieved from http://www.healthnews.com/disease-illness/healthnews-dozen-top-12-

drugs-most-searched-internet-2031.html.

Nierenberg, A. A. (1999). Management of patients on anti-depressant therapy.

Journal of Clinical Psychiatry Monograph Series, 17(1), 22-25.

Persi, J. (1997). When emotionally troubled teachers refer emotionally

troubled students. School Counselor, 44 (5), 344-352.

Phillips, D., & Orton, R. (1983). The new causal principle of cognitive learning theory:

40

Perspectives on Bandura's 'reciprocal determinism.' Psychological Review, 90, 158-165.

Pilcher, J. J. (1998). Affective and daily event predictors of life satisfaction in

college students. Social Indicators Research, 43 (3), 291-306.

Rockoff, J. D., & Wang, S. S. (2008). Drug-makers, facing critics, will stop some ads.

Wall Street Journal, 252 (138), B4.

Royne, M., & Myers, S. D. (2008). Recognizing consumer issues in DTC pharmaceutical

advertising. Journal of Consumer Affairs, 42, 60-80.

Schwenk, T.L. (2005). Influence of direct-to-consumer advertising on antidepressant

prescriptions. Archives of Disease in Childhood, 90, 874.

Viale, P.H., & Yamamoto, D.S. (2004). The attitudes and beliefs of Oncology Nurse

Practitioners regarding direct-to-consumer advertising of prescription medications.

Oncology Nursing Forum, 31, 777-784.

Waraich, P., Goldner, E.M., Somers, J.M., & Hsu, L. (2004). Prevalence and

incidence studies of mood disorders: A systematic review of the literature.

Canadian Journal of Psychiatry, 49, 124-138.

Wedekind, J. (2008). Dr. Jarvik doesn‘t row. Multinational Monitor, 29, 60.

Young, D. (2004). FDA issues new guidance on drug ads. American Society of Health-

System Pharmacists. Retrieved from

http://www.ashp.org/import/news/HealthSystemPharmacyNews/newsarticle.aspx.

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Figure 1.1

Anonymous Survey Consent

You are invited to participate in a research project entitled The Effects of Anti-Depressant

Advertising on the Perception of Depression in College Students designed to analyze the effects, if any, of anti-depressant advertising on college students‘ perceptions of depression and its treatment. The study is being conducted by Dr. Chris Swindell –Primary Investigator and Deirdre Robertson – Co-Investigator from Marshall University. This research is being conducted as part of the thesis requirements for Deirdre Robertson. This survey is comprised of 15 questions regarding depression and anti-depressants, and 3 questions about particpants‘ overall knowledge of depression. The survey will take 5-10 minutes to complete. Your replies will be anonymous, so do not put your name anywhere on the form. There are no known risks involved with this study. Participation is completely voluntary and there will be no penalty or loss of benefits if you choose to not participate in this research study or withdraw. If you choose not to participate you may either return the blank survey or you may discard it. You may choose to not answer any question by simply leaving it blank. Returning the survey to the researcher indicates your consent for use of the answers you supply. If you have any questions about the study you may contact Dr. Chris Swindell in the Communications Building of Marshall University or Deirdre Robertson at (304) 733-4003. If you have any questions concerning your rights as a research participant you may contact the Marshall University Office of Research Integrity at (304) 696-4303. By completing this survey and returning it you are also confirming that you are 18 years of age or older. Please keep this page for your records.

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Figure 1.2

Informed Consent Form I agree to participate in the observational research conducted by Deirdre Robertson. I understand that the proposed research has been reviewed by the Marshall University Institutional Review Board and that to the best of their ability they have determined that the observations involve no invasion of my rights of privacy, nor do they incorporate any procedure or requirements which may be found morally or ethically objectionable. If, however, at any time I wish to terminate my participation in this study I have the right to do so without penalty. If not 18 years of age, please do not participate in this study. If you have any questions about this study, you should feel free to ask them now or anytime throughout the study by contacting Deirdre Robertson

You may report any objections to the study, either orally or in writing, to any of the following people: Dr. Chris Swindell Supervisor Department of Journalism and Mass Communication Communications Building

Deirdre E. Robertson Primary Investigator 414 Garden Lane Huntington, WV 25705 (304) 733-4003

Purpose of the Study: The researcher intends to measure the perceptions of Marshall University students regarding depression and its treatment, and explore any link between said perceptions and popular advertisements. I understand that to maintain anonymity in analysis and reporting, no participant‘s name will be saved. All experimental data will be separated from the signed consent form to preserve confidentiality. Only members of the research group will have access to the data from this experiment. I understand that in signing this consent form, I give Deirdre Robertson and associates on this project permission to present this work, both in written and oral form, without further permission from me. Name:_____________________________ Signature:__________________________

Date:______/______/______

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Figure 1.3

Debriefing Form

This form is to inform participants about the true purpose of the study. To avoid bias, the researcher withheld this information initially. The commercial which was presented was created by the researcher in order to determine how strong an effect advertisements have on college students‘ perceptions of depression. The researcher included several incorrect statements in the commercial in order to determine whether incorrect information could influence said perceptions. The incorrect statements were as follows: - Anti-depressant medications will not cause withdrawal symptoms when ceased suddenly. - Depression causes suicide. - Depression can be diagnosed in one doctor‘s visit, and treatment can be decided in the same visit. The study is being conducted in order to determine whether there is a link between advertisements for anti-depressants (through television) and incorrect perceptions of depression and treatment. The researcher is also analyzing actual anti-depressant advertisements to determine whether or not incorrect information is being included. If you have any further questions, would like to know the results of the study when it is completed, or would like your data to be excluded from the study, please contact the following: Deirdre E. Robertson Primary Investigator 414 Garden Lane Huntington, WV 25705 (304) 733-4003 Thank you for your participation.

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Figure 2.1

0

1

2

3

4

5

6

7

8

9

10

q1 q2 q3 q4 q5 q6 q7 q8 q9 q10q11q12q13q14q15

Significance

F

The chart above demonstrates that there were no significant differences in accuracy for any question but question twelve (Depression causes suicide), in which accuracy did differ with a 0.03 level of significance. The results for question eight (Antidepressants are non-habit forming) demonstrate that the respondents disagreed significantly with the correct statement provided in the commercial corresponding with that question; the researcher can only infer that the participants had outside knowledge that contradicted with the question. The overall inference is that there is no direct link between the advertisement conditions and participants‘ responses.

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Figure 3.1 Questionnaire:

The following is to determine demographics; please answer honestly

Age:

Major:

Gender: Male or Female

The following survey is meant to measure attitudes and perceptions of depression and its treatment.

Please answer the questions as honestly as possible in order to achieve the best results. Please follow the

directions carefully.

Please circle T for statements you consider true, or circle F for the statements you consider

false.

1. Depression is a mental disorder.

T F

2. Depression has genetic traits.

T F

3. Women are more likely to suffer from a depressive disorder.

T F

4. Anti-Depressants will not cause withdrawal symptoms when ceased abruptly.

T F

5. Someone suffering from Depression is likely to be irritable and aggressive.

T F

6. Depression is a disease.

T F

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7. Depression is caused by a chemical imbalance in the brain.

T F

8. Anti-depressants are non-habit forming.

T F

9. Depression can be a chronic problem.

T F

10. Depression can have physical symptoms, such as headaches, digestive disorders, and

chronic pain.

T F

11. People suffering from Depression tend to suffer from a sleeping disorder, such as

hypersomnia or insomnia.

T F

12. Depression causes suicide.

T F

13. Anti-depressants can have physical side-effects.

T F

14. Depression is a common problem; most people will experience or come in contact with

depression at some point during their lives.

T F

15. Depression can be diagnosed in one doctor‘s visit, and treatment can be decided in the same

visit.

T F

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Figure 4.1